It is one of the causes of morbidity and mortality
following # in patient with multiple injury
FES is an important cause of ARDS
Fat embolism syndrome is defined -- Post Traumatic
Respiratory Distress Syndrome occurring within 72hrs
of skeletal trauma
Earliest manifestations are
-- Elevation of temperature above 38 deg
-- falling PaO2
Fat embolism - this indicates presence of fat
globules in lung parenchyma and peripheral
circulation after fractures of long bones and other
Fat embolism Syndrome-
A serious manifestation of the phenomenon of
emboli resulting in a variety of symptoms
In 1861, Zenker described fat droplets in the lung
capillaries of a railroad worker who sustained a fatal
thoracoabdominal crush injury.
In 1865, Wagner described the pathologic features of
However, in 1873,Von Bergmann
became the first to establish the
clinical diagnosis of fat embolism
In a 38-year-old patient who
sustained a comminuted fracture of
the distal femur.
Postmortem examination revealed
a large amount of pulmonary fat
Button – stated that 10% of battle casualities in
World War 1 suffered from FES
World War 2 postmortem study revealed incidence of
FES in 65% of patients.
1. Presence of torn
blood vessels to
permit fat to enter
2. Liberaration of free
1. A transient rise in
above venous pressure
to allow fat droplets to
enter the circulation
fat to chemically
toxic free fatty acids
that cause severe
This causes severe
Recent work by Barie and colleagues
demonstrates that free fatty acids are
bound rapidly by albumin
and transported through the
bloodstream and lymphatic channels
in this benign form.
mediator at the
site of fracture
solubility of lipids
results in coalition
What is the effect of along bone
An abundance of tissue thromboplastin
is released with the marrow elements
after long-bone fracture
Intravascular coagulation by-products such as fibrin
and fibrin degradation products then are produced
These blood elements, along with leukocytes, platelets,
and fat globules, combine to increase pulmonary
vascular permeability, both by their direct actions on the
endothelial lining and through the release of numerous
In addition, these same substances activate platelet
most common etiologic factor –
-a high-energy Trauma to long bone or pelvis, including
2nd or 3rd decade of life
or in a patient in the 6th-7th decade of life, when low-energy
fractures of the hip are frequent.
Early persistent tachycardia
Patients become febrile with high-spiking temperatures
Patients become tachypneic, dyspneic, and hypoxic
due to ventilation-perfusion abnormalities 12-72
hours after injury.
Subconjunctival and oral hemorrhages and petechiae
• Alert clinicians may notice
petechiae developing over the
upper body, particularly in
•only 20-50% of
patients and resolve
• virtually diagnostic
Central nervous system dysfunction initially
manifests as agitated delirium but may progress to
or coma and frequently is unresponsive to
correction of hypoxia.
Retinal hemorrhages with intra-arterial fat
globules are visible upon funduscopic examination.
Raise in temprature (39-40deg C)
Tachypnea 30min or higher
Tachycardia-- > 140min or higher, BP is usually WNL
Long tract signs extensor posturing and deceribrate
Urinary incontinencehealthy patient with long bone
# showing urinary incontinence needs to be ruled out
CT-HEAD-Cerebral edema & Haemorrhagic infarcts in
white matter may be seen.
one sign from major and at least
four signs from the minor criteria
petechiae in a “vest” distribution
hypoxia, with a PaO 2 less than 60 mm Hg
tachycardia, with a heart
rate greater than 110
pyrexia, with a
temperature higher than
103° F (39.4° C)
fat in urine or sputum
an unexplained drop in
hematocrit or platelet
an increasing erythrocyte
Ranges from O2 admn to full resp. support with
On pulse oximetry—
a)If PaO2<90mm=ABG analysis.
b)If PaO2 b/w 60-90mm=O2 by mask,
wait &watch for any deterioration.
c)If PaO2<60mm=INTUBATE &
VENTILATE. PEEP if required.
TREATMENT OF SHOCK
SEVERITY OF FAT EMBOL. IS
DIRECTLY PROPORTIONAL TO
DEGREE OF SHOCK.
-they also decrease inflam.reaction in lungs caused
Decrease capillary leakage by stabilizing lysosomal
& capillary membranes.
Prophyllactic dose of Methyl Pred.in high risk
patients=10mg/kg body wt./q8h i.v(in 100ml saline).
2)ALCOHOL-Decreases ser. Lipase
activity,limits lipolysis of fat & decr.FFAs
3)APROTININ-Protease inhibitor.Decr. Plat.
Aggreg.& serotonin release.Decr. Incidence of
fat emb. From 15% to 5%.
Decreases production of FFAs.
TIMING OF # STABILIZATION
RIGID EARLY IMMOBILIZATION.
Seibel et al-10 days of skeletal traction of fracture
femur with respect to early definitive # treatment-
a) x2 duration of ventilatory failure.
b) x4 no. of fracture complications.
c) x10 no. of positive blood cultures.
TYPE OF STABILIZATION
Reamed v/s Unreamed Femoral nailing.
Pape et al-In patients with thoracic injury reaming
has high rates of ARDS(33% v/s 8% for unreamed).
Many studies disproove/attempt to disproove it.
So it is INCONCLUSIVE/DEBATABLE.